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GLOUCESTERSHIRE SAFEGUARDING CHILDREN BOARD

SERIOUS CASE REVIEW

SUBJECTS

Abigail and her siblings Bobbie, Charlie and Daisy

1: SILP Overview Report

2: Additional Section following Criminal Proceedings

PUBLISHED: 20th August 2014

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SUBJECTS

Abigail and her siblings Bobbie, Charlie and Daisy

OVERVIEW REPORT

2 March 2014

CONTENTS

1. Introduction to SILP Page 3

2. Introduction to the case Page 4

3. Family Structure Page 4

4. Terms of Reference Page 5

5. The Process Page 5

6. A brief background prior to the scoped period Page 6

7. Key practice episodes Page 11

8. Analysis by theme Page 23

9. Conclusions and lessons learned Page 40

10. Findings/recommendations Page 46

11. Bibliography Page 48

Appendices

1. Terms of Reference and Project Plan

2. Agency Report pro-forma

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1 Introduction to the Significant Incident Learning Process (SILP)

1.1 SILP is a learning model which engages frontline staff and their managers in

reviewing cases, focussing on why those involved acted in a certain way at

the time. This way of reviewing is encouraged and supported in the new

Working Together to Safeguard Children published in March 2013.

1.2 The SILP model of review adheres to the principles of;

proportionality

learning from good practice

the active engagement of practitioners

engaging with families, and

systems methodology.

1.3 It has been generally accepted that over recent years the Serious Case

Review (SCR) agenda had become over-bureaucratic and driven by Ofsted

ratings. The practitioners in the case have often been marginalised and their

potentially valuable contribution to the learning has often been under-valued

and under-utilised.

1.4 SILPs are characterised by a large number of practitioners, managers and

Safeguarding Leads coming together for a learning event. All agency reports

are shared in advance and the perspectives and opinions of all those involved

are discussed and valued. The same group then come together again to study

and debate the first draft of the Overview Report.

1.5 Gloucestershire Safeguarding Children Board have requested that the SILP

model of review be used to consider the circumstances of child Abigail and a

number of her siblings, in order to learn lessons about the way that agencies in

Gloucestershire work together to safeguard children.

1.6 Working Together 2013 states that SCRs and other case reviews should be

conducted in a way which;

recognises the complex circumstances in which professionals work

together to safeguard children; seeks to understand precisely who did

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what and the underlying reasons that led individuals and organisations to

act as they did;

seeks to understand practice from the viewpoint of the individuals and

organisations involved at the time rather than using hindsight;

is transparent about the way data is collected and analysed; and

makes use of relevant research and case evidence to inform the findings.

1.7 This review has been undertaken in a way that ensures these principles have

been followed.

2 Introduction to the Case

2.1. Abigail was admitted to hospital in November 2012 due to serious concerns

about her health and development. Despite being nearly 3 years old Abigail

was unable to walk and was having a number of other problems caused by

physical, emotional and developmental neglect. These included severe nappy

rash, anaemia, malnutrition, head lice infestation and decreased bone

mineralisation (i.e. weak bones).

2.2 Both parents have been charged by Gloucestershire Police for criminal

neglect. All of the younger children in the family are now in foster care or are

placed with family members who are able to meet their needs, with the

appropriate long-term and permanent court orders in place.

3 Family Structure

3.1 The subject children:

Abigail - age 3

Bobbie – of primary school age

Charlie – of primary school age

Daisy – of primary school age

3.2 The youngest child was admitted to hospital due to the impact of

experiencing serious neglect from the parents. The other children are

included in this review due to them having similar issues and experiences.

3.3 There are a number of other older half siblings to Abigail.

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3.4 The parents of the 4 subject children are referred to in this report as:

Mother (of all the children)

Father (to Abigail, Bobbie and Charlie, step–father to Daisy)

The parents have been together since approximately 2007, and are

married.

4 Terms of Reference

4.1 The detailed Terms of Reference and Project Plan appear at Appendix 1. The

purpose, framework, agency reports to be commissioned and the particular

areas for consideration are all described there. What the agency authors

were asked to analyse and the format of the agency report appears at

Appendix 2.

4.2 It was agreed that the scope of this review would be from 5 August 2010

when a strategy meeting was held due to concerns about the children, until

23 November 2012 when Abigail was admitted to hospital.

5 Process

5.1 A number of family members were contacted in order to ensure their views

were considered and heard as part of the review. Neither Mother nor Father

agreed to meet with the Independent Reviewers. Three telephone

conversations were held with them, and although a number of appointments

were made they were subsequently cancelled by the parents.

5.2 The Reviewers met with the oldest sibling, who is now living independently of

the family, on 4 July 2013. The Overview Author and the Named Nurse

Safeguarding Children, Gloucestershire Care Services NHS Trust, visited the

children’s Grandmother on 2 October 2013. This visit was arranged later as

the Learning Event had determined how significant she had been during the

period being considered by this review. The sibling and the Grandmothers

views and information have been considered and will be referred to in this

report.

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5.3 A meeting for authors of individual agency reports was held on 17 May 2013,

where the SILP process and expectations of the agency reports was

discussed. A full day Learning Event took place on 9 September 2013. Most

of the agencies involved were represented by both the report author and staff,

including managers, who had been involved during the scope period. All the

agency reports had been circulated in advance.

5.4 The GP surgery used the completion of their agency report as a learning tool

for all staff, holding a meeting to look at the TOR and the report format, and

considering as a team what happened and why. While not requested this was

a positive way to learn lessons from the process.

5.5 At a recall session on 10 October 2013 participants who had attended the

Learning Event considered the first draft of this report. They were able to

feedback on the contents and clarify their role and perspective. All those

involved contributed to the conclusions about the learning from this review.

The final version of this Overview Report was presented to the GSCB Serious

Case Review sub-group on 22 October 2013, the Executive Committee on 4

February 2014 and the GSCB on 20 February 2014.

5.6 The review has been chaired by Donna Ohdedar, an independent

safeguarding consultant with no links to Gloucestershire Safeguarding

Children Board (GSCB) or any of its partner agencies. This report has been

written by Nicki Pettitt an independent child protection social work manager

and consultant, who is also independent of GSCB and its partner agencies.

5.7 The process has been efficiently administered by Tahidul Alam of the GSCB.

6 The background prior to the scoped period

6.1 The family has been known to a number of different agencies for over 16

years. Both of the parents had physical and mental health issues requiring a

high level of contact with health practitioners. Over the 27 month period

specified as in scope for this review there were 127 recorded contacts noted

with Primary Health Care alone.

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6.2 It is clear that poor home conditions have been an issue throughout the years

of involvement with services. When Mother had her first child, it was noted on

the primary visit from the Health Visitor that there was ‘a dead mouse under

the cot, with fleas visible on the furniture’. The Agency Report for community

health states that ‘regularly the house was noted to be dirty, untidy and

smelling of faeces’. There were concerns about all of the children not

reaching their developmental milestones at times, and that outstanding

immunisations and other health issues were not always addressed by the

parents.

6.3 On occasion other concerns also emerged. In 1999 the Police were involved

when Mother alleged that her then husband had physically assaulted and

injured their 3 year old child. This resulted in him receiving a Police caution.

The Police Officers involved also commented on the children and home being

unkempt and smelly.

6.4 In 2006 Mother’s next husband was convicted of sexually abusing two of the

children. At this time neglect was again raised as an issue with the children

and the home being described as ‘filthy’ and overcrowded by the Police

Officers involved.

6.5 In 2007 an Initial Child Protection Conference was held due to concerns

about the state of the home and the physical neglect of the children. The

decision about whether the children should be made subject to a Child

Protection Plan (or placed onto the Child Protection Register as it was then)

was ‘deferred’ as there had been improvements. As this improvement was

assessed to have been maintained by the time of the Child Protection

Conference Review, it was cancelled.

6.6 This improvement was not maintained in the longer term however, and there

continued to be concerns about the children. These were exacerbated by

Mother marrying the younger children’s Father in around 2007 and then going

on to have more children. Father is known to have potentially significant

issues of his own. There were a number of contacts and communications

made to Children’s Social Care (CSC) but the children were mostly the

subject of short term assessment and interventions, including under a CAF

(Common Assessment Framework - an early help model.) This approach

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relied on the parents to work in partnership with professionals and them

recognising they needed to improve.

6.7 In 2009 Education Welfare became involved due to the poor attendance at

school of some of the children.

6.8 Abigail was born in 2009. The midwife recorded that mother had previous

psychological problems, post-natal depression, prior contact with psychiatry

services and a chronic pain problem. When attending after the birth of the

child the midwife describes chaos, with rubbish and clutter everywhere, dog

faeces seen on the bath mat, and a smoky atmosphere. She referred to CSC

citing her concerns about parental capacity, including information that the

older children were young carers. The midwife also identified that parents

were co-sleeping with Abigail and were not taking professional advice on the

risks involved with this.

6.9 An initial assessment was undertaken by CSC in response to the midwife’s

referral, and a multi-agency meeting was held attended by the Health Visitor,

nursery nurse and school nurse, along with the parents. The parents agreed

to improve the state of the home and the meeting concluded that the nursery

nurse and Health Visitor would monitor the situation. The parents agreed to a

CAF and this was completed and managed by Homestart, a voluntary agency

that undertakes community based family support work with under 5’s.

6.10 It is clear from the history available to the review through the Agency Reports,

and from discussion at the Learning Event, that a number of the older siblings

also had similar issues to those now identified in respect of the younger

children. These historic issues included very poor home conditions, severe

head lice and nappy rash, missed appointments, poor attendance, and

professional concerns about inappropriate diet and the over reliance on cow’s

milk. There was ongoing evidence that the parents often avoided

professionals and that Mother prioritised her own needs. Early in 2010 a

Safeguarding Nurse wrote to the CSC Referral and Assessment team to state

that the on-going neglect was having a wider impact, with the children

‘showing signs of distress as a result of the neglect they were experiencing’.

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6.10 Doctors at the family’s GP practice know the family well and have been

involved with the family since 1997. The information shared with this review

provides valuable background information. This includes concerns during

2010 that the family would often refuse entry to and turn away health

professionals. The GP also provided helpful information about the mental and

physical health needs of both parent. The most significant being;

Father’s mental health issues, including a history of suicide gestures,

Mother’s history of depression,

Father’s tendencies to miss his own health appointments, leading to

physical health problems,

Mother’s mobility and health issues, some of which have not been

investigated due to lack of engagement, and are therefore unexplained.

6.11 The GP also provided a history of poor home conditions, and a view that the

eldest sibling and their partner provided a lot of care to the younger children

and helped to look after the home.

6.12 The older children’s schools had a number of concerns during this period.

There is evidence of letters being sent to CSC, not all of which were recorded

or available on the social care records. The secondary school attended by

one of the siblings (not a subject of this review) had written a number of

letters explaining their concerns for the child. They included a strongly worded

letter on 8 June 2010, copied to a senior manager, expressing clearly the

level of concern the school had for the children and their frustration that

Parents were not engaging in the CAF process. The report author for

Children’s Social Care could not find any response to this letter, or any others

sent by the school.

6.13 The information shared with CSC about this sibling is relevant to this review,

as the school Agency Report for this review states that the sibling was very

small for their age, had very poor hygiene, head lice, a huge appetite in

school and was ridiculed by their peers and increasingly isolated. This

description does lead us to question why something wasn’t done at the time.

6.14 During 2010 Bobbie and Charlie were referred to the hospital doctor due to

concerns about poor physical and developmental progression. They had also

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missed all but one of their immunisations, despite the parents signing a

consent form for them all. Charlie was seen by the paediatrician at 22 months

old in June 2010. Charlie was not walking and had friction burns and pressure

marks from crawling. A heavy scalp infestation of head lice was also noticed.

Despite this, there was reportedly some improvement seen, and the children

were discharged from the hospital doctor’s care after the family did not attend

follow-up appointments during 2011.

6.15 The safeguarding nurse wrote to a team manager in CSC on the 19 March

2010 outlining some of the concerns about the children. It ended with ‘I have

grave concerns about the immediate risks to the children and the long term

implications for this family and I would welcome a response from you as to

whether a strategy meeting could be called or a meeting take place between

ourselves which would initiate the resolution policy.’ The review was informed

that no response was received to this letter, and that CSC does not have the

letter in their records. However on 29 October 2013 the CSC agency report

author informed the overview author that this letter has in fact been found

and that CSC undertook an initial assessment and decided that no further

action was required. What is not clear is the author’s view of the content, the

quality or the conclusions of this assessment. As it was not within the scope

of this review, it has been agreed that further details will not be pursued. It

does however raise issues about both record keeping and the ability to

source historical information on children.

6.16 It is also not clear whether the safeguarding nurse took any action to follow-

up her intention to initiate the resolution policy, there does not appear to have

been any further contact until a further letter was sent on 21 May 2010 stating

that the safeguarding nurse had been asked to chair a meeting between

health and education regarding the family, and requested that CSC send a

member of their team to update on an incident involving one of the older

siblings. The meeting went ahead, but CSC did not attend. This was

because the children were seen as a CAF (early help) matter, and they did

not wish to attend a meeting without the parents being invited.

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7 Key Practice Episodes

7.1 This review will now focus on the key practice issues during the period that

this review will concentrate on. There were 4 key practice episodes before 23

November 2012.

They were:

August 2010 to January 2011 - strategy meeting leading to a core

assessment

January 2011 to May 2011 – emerging concerns about Abigail

June to July 2011 – continuing concerns

From February 2012 – escalation of concerns leading to a

professionals meeting

August 2010 – January 2011

Strategy meeting leading to a Core Assessment

7.2 A strategy meeting was held in August 2010, after a local Children’s Centre

had informed the Children’s Social Care Referral and Assessment team that a

young man was living with the family who may pose a risk to children. There

were also a number of concerns reported to CSC from Daisy and an older

sibling’s schools about their appearance and presentation, including

persistent poor hygiene.

7.3 It has been discussed during this review whether the meeting was held

because of the concerns about the man’s presence in the house, or because

of the on-going neglect concerns. It appears that the other agencies attending

and the CSC manager responding to the contact in May from the Nurse

Consultant were under the impression that it was held because of neglect.

7.4 The meeting acknowledged that there was a CAF in place and that it did not

meet the needs of the children. The content and subsequent outcome of the

meeting appeared to focus predominantly on whether the young man posed a

risk, rather than the neglect issues. It was agreed that the threshold for a

child protection conference was not met, but that a social worker should

complete a core assessment, to be undertaken under section 17 of the

Children Act 1989 (child in need). This required both the permission and

cooperation of the parents.

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7.5 A delay followed, with the assessment starting in October 2010, and

completed in January 2011. The assessment was undertaken by an

experienced Family Support Worker (FSW) rather than a qualified social

worker, as was acceptable practice at the time. (See below for improvements

in practice since 2011.) The issues identified were poor hygiene, limited diet,

lack of interaction with and stimulation of the children by the parents, some

developmental delay, anaemia, delays in immunising the children, and

chronic head lice. Both parents had alleged chronic physical health issues

which limited their mobility and ability to keep the house clean, with the older

siblings appearing to assist with the cleaning up that did take place. The

assessment concluded however that the risk was reduced due to the warmth

and love the Mother showed to her children. This is questioned by the CSC

Agency Author who is concerned about how this conclusion was drawn,

considering Abigail was rarely seen at home visits or was left in her seat for

the duration of the visit.

7.6 The parents were not willing for the assessment to be shared with key

agencies, including the schools. As the assessment was undertaken on a

child in need basis, this request had to be respected. There were three

schools and a Children’s Centre involved at the time, and staff there were not

updated on the outcome of the assessment or involved in plans for future

work with the family. The Agency Report submitted by CSC reflects that

because the level of risk was judged to be at S17 (child in need) this gave the

parents ‘a lot of say about who was involved’. This meant that information

which would provide detail on the impact that long-term neglect was having

on the older children was not adequately considered in the core assessment.

As the CSC Agency Author points out, the assessment did not assess the

parent’s capacity or motivation to change.

7.7 The Health Visitor received a copy of the assessment and wrote to the FSW

to clarify her concerns about poor nutrition, lack of immunisations and the

parents’ refusal to allow Abigail to be seen by a Paediatrician due to concerns

about growth. The Health Visitor had professional supervision at this time,

which concluded that the parents were unwilling to acknowledge the long-

term impact on the children of their parenting deficiencies. However this

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supervision did not result in any progression of the concerns or any formal

request for the issues to be considered a child protection matter.

7.8 In January 2011 a dentist was concerned about the level of decay seen in an

older sibling. The dentist stated it was due to neglect and he said that it was

one of the worst cases he had seen, with the child also smelling strongly of

urine.

7.9 In January 2011 Abigail was in hospital for 2 days with a chest infection. It

was recognised that Abigail had not had all of her immunisations. No other

concerns are recorded. There is no evidence in the hospital notes that CSC

were informed of the child being admitted, although it was open to the FSW at

the time.

7.10 This key practice episode was significant as the numerous concerns about

the care of the children had been shared, albeit not always as forcefully as

would have been hoped, and the opportunity to undertake a core assessment

was taken. There was an unacceptable delay in the commencement of the

core assessment, which was undertaken by an experienced but unqualified

member of CSC staff.

7.11 The assessment did identify and acknowledge the key physical neglect issues

but did not appear to reflect on the impact these would have on the children in

the long term, instead appearing to focus on the parents’ needs and the view

of the FSW that the impact was minimised by the belief that the children were

loved and experienced warmth from their mother. Significantly the Core

Assessment did not include any evidence that the children had been seen or

spoken to.

7.12 Key professionals, including those who had concerns about the children, were

not involved in undertaking the assessment as the parents refused to allow

them to be contacted or for the result of the assessment to be shared with

them. This included the children’s schools, which held a substantial amount of

both current and historical information about the family. This was not

challenged as the decision had been made to work with the family under

Section 17 (Children Act 1989) as a child in need issue. This effectively

empowered the family to pick and choose who they would and would not work

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with. There does not appear to have been any consideration of the

appropriateness of this at the time, or any revisit of the decision not to

undertake a child protection investigation or hold a child protection

conference in light of this insistence by the family to avoid the involvement of

key professionals. This was a missed opportunity.

7.13 The information from the dentist about the older sibling was shared with CSC,

and should have been considered in its own right as a child protection

concern. For a dentist to make a referral and for them to state it is one of the

worst cases they had ever seen should have been taken very seriously.

Research into child neglect suggests poor dental health is a clear indicator of

neglect. The dentist’s referral follows the NICE Guidance 2009 written for

health professionals who do not work primarily in child protection fields to help

them identify the early signs of neglect. The dentist was right to make the

referral, and the lack of follow-up was a missed opportunity. The GSCB have

explained that training of dentists in recognising and referring child protection

concerns was a recommendation of a previous review, which appears to have

had a positive impact.

7.14 From the children’s perspective nothing had changed, as there is no evidence

that the children were seen or spoken to in this key practice episode. It is

unlikely they would have been aware of the core assessments being

completed. At the time the older children would have been old enough to

have contributed in a meaningful way in the assessment and any plan that

would follow.

February 2011 – May 2011

Emerging concerns about Abigail

7.15 In February 2011 the Health Visitor asked the hospital doctor to see Abigail

as there were concerns about Abigail’s weight, which was moving down the

centiles on the growth chart. Three appointments were offered but all were

declined or not attended. The hospital doctor communicated to the Health

Visitor and GP that there might need to be a meeting about these ’compliance

issues.’ This shows good interagency communication and use of the DNA

policy. After a conversation with the GP, the Hospital Doctor agreed that

another appointment would be offered and a strategy meeting would not be

requested. The GP explained at the Learning Event that the pattern that had

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evolved at the surgery, when responding to the family missing appointments,

was to offer as many appointments as was required to ensure they were

seen.

7.16 The Health Visitor shared her concern with CSC that Abigail’s weight was

‘falling through the centiles’. On a visit undertaken by the FSW jointly with the

Health Visitor Mother was described as defensive and dismissive of concerns,

openly disagreeing with the Health Visitor. A child in need (CIN) plan (S17)

was completed and shared with the family on 25 February 2011. It was to be

reviewed in 6 weeks. The plan included the home being cleaned and

maintained, Abigail to see the paediatrician, children to attend the dentist,

daily baths/washes, head lice to be treated and for the pre-school age older

siblings of Abigail to attend the Children’s Centre. It is of note that this plan

did not include measures to improve the children’s weight, diet or

developmental delay.

7.17 The infant school Daisy and an older sibling attended reportedly had had

serious concerns about the children for some time. They had contact with the

allocated FSW, including copying in her manager when writing to her, on six

occasions during February and March 2011, including requesting a multi-

agency meeting on 28 March 2011. Their concerns focused on on-going

physical neglect and Mother’s hostility to the school.

7.18 Meetings were held to review the CIN plan on 24 March and on 13 May 2011.

The meetings were attended by the Health Visitor and the parents, and were

chaired by the Assistant Team Manager, who supervised the FSW. There

was thought to be an improvement in the hygiene of the children and the

home. The medical and dental appointments had not been kept however, and

there was no record of an update on the children’s development or growth.

There was no record of the older children being spoken to and their wishes

and feelings considered. There does not appear to be any consideration of

involving extended family in the CIN plan.

7.19 At the Learning Event as part of this process, the Health Visitor was clear that

she had been assertive about the fact that Abigail’s weight continued to be an

issue. The Chair of the meetings clarified that the meeting was aware that a

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paediatrician was involved, and that this was thought to be sufficient to

address the concerns. However, in light of the history and on-going concerns

about the older children who regularly missed health and hospital

appointments, this was optimistic.

7.20 A further joint home visit was undertaken by the FSW and HV in May 2011.

Mother was observed to be playing with the children, the professionals noted

with hindsight, that the conversation would always return to the parents own

health needs. The parents stated they no longer wanted Children’s Social

Care involved, so it was agreed that the Health Visitor would continue to

monitor the children and the case would be closed to the FSW. This was

despite the ongoing concerns about the children’s health and developmental

needs not being met.

7.21 In summary, this key practice episode was a missed opportunity to ensure the

needs of the children were thoroughly assessed and that the deficiencies

were consistently addressed. When the family did not cooperate in regards to

the key issues, such as attending the paediatrician, ensuring the children’s

dietary needs were met, and engaging with all of the relevant professionals

including the schools, the need for a child protection conference should have

been considered. The improvements were at best partial and significant gaps

in the children’s care and the wider assessment were evident.

7.22 From the children’s perspective they are unlikely to have been aware of the

child in need plan, as there is no evidence of them being involved. It is

unclear if they were aware of the efforts that key professionals, particularly

their schools and Health Visitor were making to secure suitable services for

them.

June 2011 – July 2011

Continuing concerns

7.23 On 8 June 2011 the Children’s Centre informed CSC that the older pre-school

children had not been attending day care as expected. They were told the

case was closed to CSC. The infant school continued to be concerned about

the children who attended their school. They believe they had made a further

referral, but this does not appear to have been made through the Helpdesk,

as is the procedure. They also reflected at the Learning Event that they did

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not always refer all of their concerns as they recognised that nothing had

changed and the parents continued to show animosity to them. They believed

that as the situation was chronic, and CSC had assessed before and the

threshold was not met, they did not believe anything would change if they

continued to refer the same on-going concerns.

7.24 On 13 June 2011 the FSW received an email, copied to them, from the

paediatrician about concerns that Abigail had not been brought to

appointments. They stated they were following the DNA policy and outlining

their concerns about safeguarding issues in the family. On 22 June 2011 the

school of an older sibling informed the FSW that the sibling’s hygiene had

deteriorated significantly. Neither contact resulted in the case being

reopened to CSC. It is not clear if the FSW forwarded the information to the

duty team to be seen as a new referral, or if the paediatrician and the school

thought they were in fact making a referral. The school shared that they are

now aware that they should always complete a MARF (Multi-Agency Service

Request Form) rather than email a particular worker. However it is evident

that they had not been informed that the case was now closed. Both the

Paediatrician and the school were justified, however, in expecting that some

action would be considered by CSC in light of the concerns being expressed.

7.25 As well as contacting CSC the Paediatrician also spoke to the GP, who

appears to have reassured the hospital doctor that the concerns were not at a

severe level. It was agreed between them to give the family another chance

of attending, and a further appointment was therefore offered to the family at

the hospital.

7.26 The same month the Health Visitor made a home visit after becoming aware

that Abigail had missed three scheduled appointments with the Paediatrician.

At the visit she noted that Abigail was not yet crawling or walking, and that no

significant amount of weight had been gained. Advice was again given about

nutrition and stimulation. A further visit was undertaken shortly afterwards and

Abigail was said to be asleep. The parents reported that Abigail was now

crawling and weight bearing. It is significant to note here that the interview

undertaken recently with the older sibling provided information that the

parents would put the children to bed when they were expecting a visit from

the Health Visitor. This is likely to have been one of the occasions when this

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happened. It certainly allowed mother to provide information about her child’s

progress that was later found to be untrue. At the Learning Event the Health

Visitor clarified that she would attempt to time her visits at different times of

the day in the hope of seeing Abigail awake, and to try and see the children at

meal time, which did not happen.

7.27 On 29 July 2011, six weeks after the decision to offer another appointment,

Abigail was assessed by the hospital doctor, but was not physically examined

as Abigail was reluctant to leave mother’s lap. The information noted by the

hospital doctor is mostly as reported by the parents. There is no evidence that

the specific issues raised by the Health Visitor were considered. The child

was discharged to the care of primary health services. (GP and Health

Visitor.)

7.28 No significant issues emerged during the next 6 months.

7.29 This key practice episode is significant because further concerning

information was being noted and raised about the children, none of which led

to a referral formally requesting the intervention of CSC. There are also signs

that the professionals working with the children were becoming increasingly

demoralised about both the family and the likelihood of the matter being seen

as a safeguarding issue by CSC. This was not identified at the time however.

7.30 Again, there is little or no evidence of the children being spoken to or directly

observed during this key practice episode.

From February 2012

Escalation of concerns leading to a professional’s meeting

7.31 During 2012 Bobbie missed 4 out of 5 appointments with the hospital

ophthalmology team. This is despite the parents being sent information that

explained that the child’s sight could be affected long-term without

appropriate interventions.

7.32 In February 2012 there was a change of Health Visitor. The new worker took

the opportunity of discussing the family with the GP. The GP said they were

not concerned that Abigail was walking late, as they were following the

pattern of an older sibling who also walked late. The Health Visitor did

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establish that both parents suffered with depression and that father was

addicted to a prescription pain killer and to Diazepam. After a number of

attempts the Health Visitor was able to undertake a developmental review of

Abigail. The locomotor skills were that of a 15 month old (Abigail was 28

months old at the time). The weight remained on the 2nd centile. The Health

Visitor wrote to the GP and the Paediatrician with her concerns. The Agency

Report from the hospital points out that a request for an appointment was not

made, and that the Health Visitor may have been under the impression that

Abigail was still under consultant appointment follow-up, which she was not. A

further appointment was not offered by the Paediatrician.

7.33 The Health Visitor took her concern to her safeguarding supervision and the

plan was to ‘liaise’ with other professionals and to monitor Abigail’s

development. On reflection, this could raise concerns about the effectiveness

of this supervision. Information obtained at the learning event highlighted that

paper records were kept with plans from supervision, however they were not

available at this time. This meant that previous interventions were unknown,

and the resulting lack of consistency was exacerbated by a new professional

becoming involved.

7.34 Bobbie and Charlie were both supposed to be attending the Children’s Centre

nursery at this time, but their attendance was just 12 – 15%. In September

2012 the Children’s Centre worker visited the family and was concerned

about Abigail. She appeared unwell and they were told she had bad nappy

rash. Father later told them that cream had been prescribed and that she was

getting better. The Children’s Centre expressed their concerns to the Health

Visitor.

7.35 Health professionals were increasingly concerned about Abigail from around

July 2012 when the nappy rash was identified as problematic. There had also

been concerns about failure to thrive identified in a letter from a Paediatrician

to the family, copied to the GP, who had stated that there was a potential

safeguarding issue. The GPs also spoke to the parents about their concerns,

and had weekly contact with the family over the next few months, as well as

liaison with the Health Visitor. There was no contact with CSC until 17

October 2012.

20

7.36 The GPs had requested that a hospital admission be considered by parents in

respect of the nappy rash, but the parents refused, insisting that there was an

improvement in the matter. The GP involved at the time accepted the

parents’ report of improvement, and made the decision not to force hospital

admittance. This decision was made without seeing the child. In hindsight this

was a missed opportunity to intervene in the children’s lives a little earlier.

7.37 The reviewers spoke to the eldest sibling of Abigail as part of this review. The

sibling was living at home when Abigail had severe nappy rash. The

reviewers were told that the parents did not use the prescribed medication to

treat the nappy rash. The sibling reported that Mother had ensured that the

cream be thrown away, so that when the Health Visitor visited and checked

the medication it looked like it was being used. No one appears to have

spoken to the teenager to gain their view of the situation at home. While they

may not have made this disclosure, there is a possibility this information may

have been shared at the time.

7.38 In this key practice episode the Health Visitor made many attempts to see the

family and particularly Abigail. Most of the visits were missed by the family,

and on the rare occasions access was granted, the Health Visitor continued

to have concerns about the child’s weight, unsteady walking, and persistent

head lice. The Health Visitor was also informed by the GP of the concerns of

a receptionist at the surgery, who had seen Abigail and father in the waiting

area, and that Abigail kept saying ‘sorry’ to father. The receptionist had been

very concerned. During this phone call the GP also stated that both parents

were addicted to analgesics, and that father had issues with the use of both

cannabis and alcohol.

7.39 No new referral was made to Children’s Social Care until 17 October 2012

when a referral was made by the Health Visitor using the Multi-Agency

Service Request Form. This was after a further safeguarding supervision

session where the Health Visitor reflected on a further number of visits to

review the nappy rash which were refused or missed by the family. The

referral included information about the severe and chronically infected nappy

rash being suffered by Abigail, a severe infestation of head lice in the

children, and the parents’ lack of ability to prioritise the children’s care over

21

their own needs. In light of this referral and a joint visit between the Health

Visitor and a duty Social Worker on 31 October 2012, it was agreed that a

strategy meeting should be arranged.

7.40 It was clarified in December 2013 that the referral to Children’s Social Care

made by the Health Visitor on 17 October was initially closed in error, but the

mistake was discovered and rectified on 22 October, when the child’s case

was opened for assessment. A letter arranging a visit was sent to the family

on 26 October, they were spoken to on the 29 October, and visited on 31

October. When questioned why the referral was not treated more urgently, it

was explained by the agency that as a number of professionals were actively

involved, and the nappy rash had been an issue since June, it was not

thought to be urgent at the time.

7.41 CSC and Police had a strategy discussion on 6 November 2012, and it was

agreed to undertake S47 enquiries that included completing a core

assessment. This happened in agreed timescales, with some of the older

children being observed by the Social Worker on 19 and 20 November. The

core assessment included information from key professionals. For the

children there was no action taken to change their situation however until

after 21 November when a further meeting was held. During these additional

weeks Abigail would have experienced further damaging neglect.

7.42 On 30 October 2012 the GP spoke with the newly allocated duty Social

Worker. The GP voiced his frustration by stating he just wanted the family to

be made to attend all the appointments that had been offered. When

reviewing Abigail and the nappy rash over the next few weeks the GP noted

that the situation was much the same.

7.43 During October and November 2012 a professional who was not a child or

adult services worker spent a significant amount of time in the family home,

on an entirely unrelated remit. They contacted Children Social Care on 19

November 2012, stating they were ‘shocked and upset’ about the state of the

home and the children. They provided particular details about Abigail who

they described as still in nappies with nappy rash, that Abigail looked

neglected and dehydrated, was grubby and seemed to be underweight. They

22

were told that the family were to be the subject of a child protection meeting

due to a referral received previously.

7.44 A ‘professional’s meeting’ was held on 21 November 2012. It was described

as a professional’s meeting rather than a strategy meeting as the Police were

unable to attend. All of the other key agencies were present however and

there was a high level of concern about the children, particularly the parent’s

failure to respond to Abigail’s health needs. It was decided to progress to

Initial Child Protection Conference.

7.45 Abigail was admitted to hospital on 23 November 2012, not to return home.

7.46 A later further strategy meeting was held on 27 November 2012 which was

attended by the Police. This meeting appears to have been called to consider

the severe neglect of Abigail and plan the investigation that was required.

7.47 This key practice episode was dominated by drift and the lack of action to

address the needs of the children. One of the contributory factors for this was

the fact that the parents were successfully avoiding professionals and the

children were subjected to further neglect and harm. While the Health Visitor

was most persistent in her attempts to access the family, and the GP made

efforts to ensure the nappy rash was treated, the acceptance of the

seriousness of the situation by all agencies was delayed and the parents

reluctance to engage and blatant avoidance of professionals was allowed to

go on for too long.

7.48 The older children watched as their youngest sibling became ill and, in the

words of the Grandmother ‘was fading away’. Again there is no evidence that

any of the older children were spoken to, and the parental lack of cooperation

led to limited opportunities for the younger children to be seen and assessed.

Until the final decisive action was taken to remove the children from the care

of their parents after the hospital admission on 23 November 2012, the

children could not have had any faith that professionals were going to

respond to their continuingly poor care.

7.49 In addition to the significant incidents listed above, it is of interest to note that

during the review period Police attended the family home on 6 occasions in

23

regards to non child protections matters, mostly complaints of criminal

damage or theft and neighbourhood disputes. On no occasion were concerns

about the state of the home identified or reported by the Police Officers

attending. When interviewed for the review, two of the Officers remembered

that the house was untidy, unclean and smelly. However they did not have

any concerns for the children at the time.

7.50 It needs to be pointed out that the practice outlined above is, at the time of

reviewing this case, at least 12 months old. Those involved in the review have

been given information about the improvements made across all relevant

areas since the time of the incidents being considered. The improvements

made are outlined in detail below, and are significant and positive. It has been

accepted that there may be further lessons to be learned or certainly that the

learning is reinforced, and this report will now outline these lessons as part of

the analysis of what happened in this case and why these children suffered

significant harm despite the involvement of a number of professionals.

8 Themed Analysis

8.1 The analysis section of the review will consider the information above, which

was gained from the Agency Reports and the Learning Event, thematically.

All of them lead to lessons that need to be learned from this review. The

themes to be addressed here are:

A. Listening to children and seeing the child’s world

B. Levels of need and the limitations of an incident led approach to child

neglect

C. The impact of professionals feeling overwhelmed or desensitised, and

the challenge of working with parents who are manipulative or show

disguised compliance

D. Professionals not feeling valued and listened to, and the lack of a

culture of resolving professional disagreements

E. Understanding neglect

At the end of each section of analysis the lesson learned will be stated, along

with a recommendation as required. These will be reiterated in the specific

sections towards the end of the report.

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A. Listening to children and seeing the child’s world

8.2 In April 2011 Ofsted published their fifth report evaluating Serious Case

Reviews. Titled ‘the voice of the child: learning lessons from serious case

reviews’ it has a single theme, the importance of hearing the voice of the

child. The report has identified five key issues which ran through many of the

cases considered:

I. the child was not seen frequently enough by the professionals involved, or

was not asked about their views and feelings

II. agencies did not listen to adults who tried to speak on behalf of the child

and who had important information to contribute

III. professionals were prevented from seeing and listening to children by

parents and carers

IV. practitioners focused too much on the needs of parents, especially

vulnerable parents, and overlooked the implications for the child

V. agencies did not interpret their findings well enough to protect the child.

8.3 Working Together 2013 has legislated to ensure that this issue is addressed

more fully by professionals working with children and their families. It states

‘Children should be seen and listened to and included throughout the

assessment process. Their ways of communicating should be understood in

the context of their family and community as well as their behaviour and

developmental stage. Children should be actively involved in all parts of the

process based upon their age, developmental stage and identity. Direct work

with the child and family should include observations of the interactions

between the child and the parents/care givers’.

8.4 There is very little evidence that the ‘voice of the child’ was heard by a

number of the professionals involved in this case, particularly those

undertaking assessments. The school were clear about the needs of the older

children and showed a good understanding of the children’s difficult

circumstances and knew the older children well. They should be applauded

for this. Letters were sent from the secondary school to CSC, cataloguing

concerns. Few received a response. It is easy to see why the school was

frustrated. It was clear at the Learning Event that they had been very

distressed over a number of years about their inability to effect positive

change for these children.

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8.5 The core assessment did not evidence that the children had been seen or

spoken to, and other professionals recorded positive updates on the children

that were reports from Mother, rather than observed themselves. Having to

witness the neglect of their younger brothers and sisters must have been very

distressing for the older siblings. The eldest child told the review that Mother

would lie to professionals constantly. It has been a regular finding from

Serious Case Reviews that professionals should be checking what they are

told by observing children directly, and speaking to children if that is age-

appropriate. Hearing the voice of the child and considering what their life is

like needs to be a key part of any assessment and work with a family, with the

information gained influencing plans and actions.

8.6 In 2012 Brown, Ward and Westlake of Loughborough University considered

the obstacles to focussing on the child when undertaking child in need and

safeguarding work. They listed them as follows:

Preservation of the family

The partnership principle

Empowerment, fairness and their limitations

Parents’ rights

All of these were obstacles in this case. Consideration of the need to work

with the parents in order to help the children, Mother’s fierce stating of her

rights, and the principle of needing parental permission to see the children

and work with other agencies under S17/Child in need, lead to a failure to see

the children in this case, both literally and metaphorically.

8.7 The review acknowledged that the older children in this family may have been

young carers, and asked if this issue was considered by the agencies

involved. The core assessment in 2010 – 11 commented on the fact that both

parents had chronic physical health issues which limited their mobility and

ability to keep the house clean, with the older siblings appearing to undertake

some household chores. The schools reported that the older sibling was

responsible for taking the children to school and collecting them.

8.8 The Core Assessment did not highlight that the older children were taking on

a significant amount of the household or child care responsibility. However it

26

is not clear if it was explored with the children or the family. There does not

appear to be any evidence that the older children’s potential role as young

carers was considered by any agency.

8.9 Learning Lessons from Serious Case Reviews 2008 - 2009 stated that ‘young

carers who may be caring for a disabled parent are not always receiving the

assessments of needs to which they are entitled and as a consequence do

not receive services which meet their needs.’ Assessing the older children as

potential young carers in this case may have made a difference to those

children, and enabled them to receive the support they needed. Grandmother

informed us that the eldest sibling ‘did not have a childhood’. It is

acknowledged however that in large families where the parents have

significant needs of their own, the older children will often play a part in the

running of the household.

8.10 Lesson 1:

Professionals in the agencies involved in this case had difficulties in keeping

a clear focus on the needs of the children, due to the need to negotiate the

many demands and difficulties of the parents. Supervision needs to play a

clear role in ensuring that assessments, plans and interventions listen to the

child’s voice and consider this information when taking actions. To quote

Working Together 2013 ‘Ultimately, effective safeguarding of children can

only be achieved by putting children at the centre of the system, and by every

individual and agency playing their full part, working together to meet the

needs of our most vulnerable children.’

Lesson 2:

The child’s experiences should be at the heart of all plans. Robust, time

bound and outcome focused plans need to be in place for all children where

there are concerns about the capacity or motivation of the parents to improve

the children’s circumstances. These plans should include extended family

members.

Recommendation 1:

GSCB to undertake an audit of assessments of child in need and child

protection plans to ensure that the child’s voice has been heard and is taken

into account in the conclusion of the assessment and throughout the plan.

27

B. Levels of need and the limitations of an incident approach to child neglect

8.11 At times during the history of this matter, both before and during the scope

period of this review, the decision was made for the children to be seen as in

need of early help or universal services, or as children in need, rather than as

children in need of protection. At no stage since the deferred conference in

2007 was the care of the children considered a child protection matter. This

was despite communications with CSC regarding the condition of the home,

concerns about the hygiene and development of the children, and issues with

the parents not cooperating with services offered, including important medical

appointments.

8.12 Despite brief periods where some improvement was noted in the state of the

home and in the presentation of the children, there were numerous concerns

about these children, which intensified during the period being considered by

this review. The assessments undertaken in relation to the younger children

did not take into consideration either the experiences of the older children,

which were well documented in a number of agencies, or the extensive

information held across agencies about both the parents and the children.

When considering the information known to professionals at the time, if a

more thorough assessment had been undertaken, including an analysis of all

agency information and a thorough chronology compiled including all the

information available since the birth of the oldest sibling, it should have been

quite clear that the children were at risk of significant harm.

8.13 The failure of the agencies to pull together historical information, covering all

of the children, appears to have led to an incident led approach and ‘start-

again syndrome’, a term described in the Biennial Analysis of Serious Case

Reviews 2003-2005. In these situations the parents’ histories are not

considered sufficiently and the focus was on the current circumstances. This

led to a lack of systematic analysis of parenting capacity, including their

motivation to change, and no acknowledgement of the lack of sustained

progress. The children’s experience of harm over a long period was being

ignored.

28

8.14 As stated in the Police Agency Report ‘‘there is evidence from the records

that each strategy meeting has perhaps concentrated on specific issues and

has not looked at wider themes or taken a more holistic view which may have

resulted in issues like neglect having been identified earlier”. Individual

concerns and incidents did not appear to meet the threshold being used at

the time for a child protection response in their own right, including the

decision to call a conference. A child protection conference would have

allowed all the professionals involved to share the history of the family and

the current concerns in a setting chaired by an independent person, where

the parents could not have decided who was involved and who was not.

8.15 Even without a child protection response to the children, the child in need

plan and S17 response to the neglect was inadequate. The review saw no

evidence of a clear, time-limited and outcome focused plan for these children,

which involved the extended family as well as the parents. Grandmother

states that despite her having regular contact with the family, she was never

contacted by professionals either for information or to request her help and

involvement in any support plan. She acknowledged that despite her own

concerns she did not contact any agency. This was due to her fear that

Mother would refuse to let her have on-going contact with the children.

8.16 The timeliness of responses by professionals to issues raised was part of the

terms of reference for this review. The Agency Reports and the professionals

around the table at the learning event acknowledged that decisive action was

not taken in relation to the on-going chronic issues they were aware of.

Delays were evident in the provision of appointments at the hospital; the start

and completion of the Core Assessment; and in the holding of key meetings,

including the meeting that resulted in Abigail being taken into hospital and

removed from the parents care. For Abigail these delays probably led to

prolonged suffering.

8.17 Lesson 3

The following issues remain of concern and require a clear message to all

agencies:

29

- The need for clarity regarding sharing information on children and their

siblings and parents, when they are not identified as a ‘child protection

case’.

- The need for clarity about the option of holding professionals meetings

without the parents attending, which may have been useful in this case.

- The need for clarity regarding the ability of all agencies to request a

strategy meeting.

Lesson 4

It is the robustness of the plan, which must include a contingency plan and the

involvement of all agencies and the family, which will ensure the needs of the

children are assessed and met. Not the status of that plan. In this case it is

clear that the plan should have made it clear that if the parents did not

cooperate fully with what was required to ensure the children’s needs were

met, that legal advice would be sought.

Lesson 5

All assessments of risk should consider and analyse the historical information

held across agencies.

Recommendation 2

The GSCB should support a framework of meetings which allow professionals

involved in particular cases to meet and reflect on professional dynamics and

disagreements without the presence of children and families.

C. The impact of professionals feeling overwhelmed or desensitised, and the

challenge of working with parents who are manipulative and show disguised

compliance.

8.18 It was clear at the Learning Event that the majority of professionals who had

known the family over the years felt both confused and overwhelmed by the

complexity of the needs of the parents and children in this family. The GP also

stated that the primary health team became desensitised to the family’s way of

living. They provided GP appointments on demand, and this led to a degree of

collusion with the parents. In the Agency Report the GP states ‘Primary Care

took the view that keeping the family on-side and making the system easily

accessible was the most practical way of handling the situation’.

30

8.19 The Health Visitor said that it was hard to be child focussed when the parent’s

needs were so overwhelming. Mother’s health always appeared to dominate

the conversation. The school agreed that this was also their experience when

trying to engage with the parents. The professionals at the Learning Event

agreed that this family ‘exhausted people’. Serious case reviews have often

commented on the difficulty, in child neglect cases, for professionals to decide

when ‘enough is enough’ and that when staff feel helpless and sometimes

fearful of families, this leads to avoidance and drift.

8.20 Grandmother told us that she would only criticise the parents so much,

because Mother would tell her to stay away. Instead Grandmother would try

and compensate for the poor parenting she recognised the children were

getting by regularly having one or two of the children to stay, or going over on

her day off and attempting to do some cleaning or laundry. This threat also

stopped Grandmother contacting CSC.

8.21 The challenge of working with parents who are manipulative and/or show

disguised compliance was a key theme when reviewing this case. The majority

of staff who were involved in this case felt that professionals require more

support, supervision and training when it comes to working with families who

are dishonest, avoidant or won’t engage. In this case the parent’s dominance

of the attention of professionals, to the detriment of their children, was an

effective way of avoiding scrutiny of their parenting. Mother was particularly

difficult to work with.

8.22 Without a robust multiagency plan that is clearly communicated to the parents,

with clear contingency planning, that does not drift or get hijacked by the

parents needs, the children’s needs were not assessed or met.

8.23 Grandmother stated that Mother is manipulative and aggressive. She felt

intimidated by Mother herself and believes that professionals would have felt

the same way. She described Mother as very controlling of her husbands, the

children and wider family. She believes Mother would also have wanted the

power and control in any relationship with a professional. She said Mother had

the potential to ‘eat them alive’.

31

8.24 The GP Agency Report states that Mother ‘was well known to all agencies to

be manipulative and at times hostile. She was skilled at playing off one

agency against the other’. The school Agency Report stated that Mother knew

how systems worked and was described as ‘calling the shots’.

8.25 Schools reported at the Learning Event that Mother could be aggressive, and

that on occasion she swore at teachers if she felt challenged. Indeed her

refusal to work with the schools in the first key episode of this review did not

lead to a reconsideration of the need for a child protection response, but to a

collusive agreement that these key professionals could be avoided if Mother

agreed to work with the Health Visitor. While this might have been agreed in

the spirit of partnership, the needs of the children were not prioritised over

their Mother’s unsubstantiated concerns.

8.26 ‘Disguised compliance’ is a term that can be attributed to Peter Reder, Sylvia

Duncan and Moira Gray in ‘Beyond blame: child abuse tragedies revisited’

(1993). It involves a parent or carer giving the appearance of co-operating

with agencies to avoid raising suspicions, to allay professional concerns and

ultimately to diffuse professional intervention. There was no doubt at the

Learning Event that both parents had adopted this stance as a way of

avoiding the agencies who had voiced concerns about the children. They

were successful for many years.

8.27 On occasion it is clear that there was over-optimism both about the

relationship between Mother and her children (her being described by the

FSW as loving the children) and regarding improvements in the children’s

development, hygiene and attendance at appointments.

8.28 Both Mother and Father had health and psychological problems of their own,

which demanded a lot of professional attention. Grandmother described

Mother as attention seeking. Grandmother also informed us that Mother loved

being pregnant and having new babies, as she got attention. Grandmother

said that after each baby was a few months old, Mother lost interest and

started to plan her next child.

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8.29 The health professionals in particular had the dilemma of how to build a

relationship with the parents, in order to see the children and progress their

work with the family, without angering Mother and isolating themselves as a

help to the children. Mother would often talk about her ‘rights’, and a number

of the professionals felt they had to carefully negotiate their position to avoid

losing any opportunity they had to engage with the family. Again, without a

robust plan to support their role, they did not feel they could push too much.

8.30 Lesson 6

All professionals working with children and families need to be trained and

supported, to include the provision of reflective supervision, in the

identification and challenge of parents who use manipulation and disguised

compliance, to ensure the needs of the child remain the priority.

Recommendation 3

That the GSCB review its model of reflective supervision, to ensure that it is fit

for purpose in assisting professionals to gain confidence in working with

parents who are manipulative and show disguised compliance. Consideration

is to be given to using this model with more complex Child in Need cases, as

well as those subject to a Child Protection plan.

D. Professionals need to feel valued and listened to, and the lack of a culture of

resolving professional disagreements.

8.31 It was clear at the Learning Event that at the time a number of professionals

struggled to make themselves heard, particularly by Children’s Social Care,

who it was felt had to make the decision about what to do to help the children.

The Health Visitor involved at the earlier stages expressed her frustration that

she was unhappy with the progress the children were making, but felt

‘impotent’ as she was told it did not meet the threshold for child protection.

She felt that it did, but that she was the lone voice.

8.32 On the 17 October 2012 the second Health Visitor made the important referral

about the nappy rash, the head lice and the parent’s failure to meet the

children’s needs, which resulted in an initial assessment being undertaken.

However staff present at the Learning Event fed back that it appeared that it

was not until the referral was made to a senior manager in CSC, by the

33

person spending time in the family home in an unrelated professional capacity

a month later, that the strategy meeting was finally held. This was clearly a

coincidence, as this was not the case. The Learning Event acknowledged that

it is understandable that the professionals involved felt demoralized and not

listened to in regards to their concerns about this family. It must be made

clear however that the case had been allocated and CSC were responding to

the health visitors referral, not the telephone call to a senior manager that was

received later.

8.33 The secondary school records show that they did not feel that front line staff in

CSC took their concerns seriously, feeling that they had to copy in senior

managers to get any response. Even this had a limited impact. The infant

school felt that relations with CSC were good in this case once the case was

allocated. The issues were when the referral was made and it wasn’t thought

to meet the threshold, then relations were often strained.

8.34 At the Learning Event schools stated that they do not feel valued as

professionals by CSC. The head of one of the schools stated that she felt

undervalued and that in her previous local authority she had a better

relationship with CSC and felt more on an equal footing with them. This

viewpoint requires exploration by both CSC and the GSCB.

8.35 Good relationships were reported between the school and health

professionals, particularly with the Health Visitors and Paediatrician. The

review acknowledges the hard work that school staff and Health Visitors put

into this family, and the attempts they made to communicate concerns, even

when parents had refused permission for the child in need plan to be fully

communicated and then continued.

8.36 There was positive communication from the Health Visitors to the GP,

particularly during the 4th key episode. A study published by the Dept of

Education in 2009 called the ‘The Child, The Family and the GP” found that

GPs preferred to consult with Health Visitors and other Health colleagues

rather than with Children’s Social Care where they had concerns that were not

clear cut’. The study found that there was a general reluctance by GPs to

approach Children’s Social Care to make referrals unless there was a clear

injury, disclosure or evidence of failure to thrive. ‘The important role of the

34

Health Visitor in safeguarding children, and as a key fellow professional for

the GP to refer to, was confirmed in this study.”

8.37 There were a number of opportunities for concerns about what was perceived

as a lack of decisive action in respect of these children by CSC, to be

escalated via the Resolution of Professional Disagreements policy. On one

occasion they were, with the Safeguarding Nurse formally escalating the

Health Visitors concerns at the beginning of the period being considered by

this SCR. On other occasions, while information and concerns were being

sent to CSC, the resolution policy was not used. The Head of the Secondary

School could have made use of the policy, and Children’s Social Care could

have directed him in the direction of the policy in response to the letters being

copied to senior managers.

8.38 It was acknowledged during the Learning Event that different agencies have

different cultures when it comes to the sending and receiving of letters. The

use of formal letters in health and education as a way of keeping other

professionals informed and updated is common, this is not the culture in

Children’s Social Care.

8.39 In 2010 GSCB undertook a major communication drive and road show in

respect of a serious case review. This included the publication of an

information poster for professionals. The poster shares the lessons learned,

and was designed for a wide audience. The first four lessons are as pertinent

to this case as they clearly were in relation to that SCR:

Advocate on behalf of your children - don’t drop the ball. Stay

responsible for the child even after referring to a different agency - always

push for the response you know is needed to fully meet the child’s needs.

Ensure referrals are of the highest quality. Use the professional

disagreements policy if you are not satisfied with the response you receive.

Sharing Information. Include all relevant information held by your agency

when making a referral, including information on all adults and children,

especially previous concerns – missing information could make all the

difference.

Be Child Focused. Always view your work through the eyes and experience

of the children and young people in the family (and always consider the

experiences of any children when working with adults).

35

Quality of Assessments. Be challenging and rigorous in your assessment of

risk – be aware of being too parent focussed, taking things at face value.

Determine what is happening to the child and ensure change is taking place.

8.40 The poster is available on the GSCB website, but this case shows that there

are still barriers to implementing and reinforcing learning, as the lack of use of

the professional disagreements policy in this case proves. The school

Agency Report states that the schools believed that no resolution policy was

available at the time, which was not the case.

8.41 The majority of agencies reflected on a problem they had all experienced

when sending referrals to CSC at the time. They stated that they couldn’t tell if

a referral had been accepted or not, often having to send repeat referrals in

order to try and get a response. It must be noted that agencies around the

table at the Learning Event reported that things have improved since the

introduction of the ‘request for service’ system. School also stated that are

now aware of the Resolution of Professional Disagreements Policy, and feel

this is useful.

8.42 While very hard working during 2012 and trying all she can to get help for

Abigail, the Health Visitor was not specific in her letters to the hospital

Paediatrician that she wanted the child seen again. The letters seemed to be

for information, rather than requesting a service. Neither the hospital doctor

nor the Health Visitor clarified what was required or was being requested. As

well as being clear with CSC about what is required for a child or family, all

staff should be clear in all communications of the purpose of the information

being shared and their expectations about what needs to happen next.

8.43 Lesson 7

All agencies need to have the confidence to challenge or question decisions

taken by other professionals in partner agencies. Clear guidelines and

training, supported by supervision, needs to give professionals the confidence

to challenge each other and to escalate any concerns they have via the

resolution policy. The review has heard that agencies defer to Social Care

when it comes to decisions about the need for services to be provided to

children in need and in need of protection. GSCB need to ensure that they

36

advertise the message, including in training, that professional disagreement is

a positive sign of a healthy safeguarding system.

Recommendation 4

That the GSCB’s new Levels of Intervention model includes a clear link to the

professional challenge policy, and is clear that requests for explanations of

why decision have been made should be sought as applicable.

E. Understanding neglect

8.44 One of the most concerning issues in this case is the apparent lack of

understanding, at the time, of neglect and its impact by a number of the key

professionals working with this family. This suggests a need to test whether

this demonstrates a wider lack of understanding of the impact of neglect

across the county.

8.45 Neglect is defined as ‘the persistent failure to meet a child's basic physical

and or psychological needs, likely to result in the serious impairment of the

child's health or development’. In this case Abigail and a number of the

siblings have experienced severe neglect that will have long-term implications

for them. As stated by Daniel et al (2011) ‘Apart from being potentially fatal,

neglect causes great distress to children and is believed to lead to poor

outcomes in the short and long-term. Possible consequences include an array

of health and mental health problems, difficulties in maintaining relationships,

lower educational achievements, an increased risk of substance misuse,

greater vulnerability to other abuse as well as difficulties in assuming

parenting responsibilities later on in life’. Grandmother informed us of her

deep sadness that all of the children would have to live with the effects of

what they experienced for the rest of their lives.

8.46 A recent SCIE systems review into another matter, and the OFSTED

inspection of 2011, both found that neglect was seen as less serious than

other types of abuse in Gloucestershire. Managers around the table at the

learning event were open with the reviewers that at the time professional

practice in regards to neglect was not good enough.

8.47 In their report ‘The state of child neglect in the UK’ (2013) Action for Children

remind us that ‘neglect is the most common reason that children are made

37

subject to a child protection plan, with neglect featuring in 60 per cent of all

Serious Case Reviews’. In August 2013 547 children in Gloucestershire were

subject of a CP Plan, of which 195 have neglect as the main category of

abuse.

8.48 All of the signs were there, and had been for many years, that these children

were suffering or likely to suffer significant harm due to neglect. At the time

there were clear difficulties in ensuring that all of the information on all of the

children was available to be considered and drawn together in order to ensure

a complete picture. If this had been done, the list of concerns would have

looked like this:

Tooth decay. Empirical evidence suggests that there is a high level of

agreement among different professional groups that poor dental health is an

early indicator of neglect. A number of the children had tooth decay and lack

of attendance at dental appointments.

Severe and persistent head lice. Both the children and the parents had

head lice most of the time. The GP Agency report states that ‘No members of

the Primary Care team assessed this as a neglect issue on its own’. The 2009

NICE quick reference guide to neglect highlights severe, persistent and

untreated infestations of head lice as an indicator of child neglect. The

Paediatrician who saw Bobbie in 2012 stated that the child had open sores on

the scalp due to untreated head lice.

Poor growth and weight gain. Most of the children were small and this was

felt to be linked, as they grew, to inadequate diet with an over-reliance on

cow’s milk. The parents did not follow professional advice, despite the fact

that the children were clearly failing to thrive on the diet they were receiving at

home. At least one of the children had rickets.

Delayed development. Walking and talking were both areas where

professionals were concerned about the delay in the development of the

younger 4 children, who are the subject of this review. No information was

available to the review on the older children but the schools have noted

concerns.

Anaemia. It was the view of the paediatrician that both Bobbie and Charlie

were suffering from severe non organic anaemia due to malnutrition in 2010-

11. The review heard that is a very serious condition for young children, which

could lead to cardiac arrest.

38

Missed health appointments. It was reported that the Parents always gave

plausible excuses for the failure to bring the children to appointments, but

there was no assessment of the impact on the children’s health and well-

being of the parents not taking them to appointments.

Failure to immunise. It is not a statutory obligation to immunise children,

with many parents opting out. In this case the parents had agreed to the

immunisations and attended some appointments, but the course was rarely

completed. This potentially left the children vulnerable.

Failure to use prescribed medication. The GP has stated that there were

issues of compliance with prescribed medication in regards to a number of

the children.

Severe nappy rash. Most of the children, but specifically Abigail, suffered

with chronic and painful nappy rash, which was not appropriately or

consistently treated by parents. Professional advice was not sought or

responded to with regards to this issue. 6 weeks before the admission, there

was an opportunity for Abigail to be taken into hospital with the severe nappy

rash. Father told the GP he would agree to Abigail going into hospital for the

nappy rash to be treated, however Mother blocked this. The GP, with the

support of the Health Visitor, pursued this, but believed the parents report that

things had improved and did not push for hospital admittance. This decision

was made without seeing the child. This was a missed opportunity to

intervene a little earlier in the children’s lives.

Poor hygiene and dirty clothes. Was an on-going issue for all the children.

This led to them being socially isolated and stigmatised.

Poor attendance at nursery and school. Again, this was an issue for a

number of the children, and most recently for Bobbie, Charlie and Daisy in

relation to the nursery provided at the Children’s Centre. The older children

had the involvement of Education Welfare on a number of occasions due to

poor attendance.

Non-compliance with advice from health professionals. This was the

case in relation to the children’s diet, dealing with health issues, and co-

sleeping with babies. It is recorded that the parents refused to listen to advice

about the dangers of co-sleeping when parents are smokers. This was a risk,

particularly as Father was alleged to drink and use cannabis.

There was a concern raised in 2012 that Mother may be using her own

medication to drug the children. This has never been proven.

39

8.49 The strategy meeting held in August 2010 did not fully acknowledge the

neglect issues which had been identified over many years, appearing to focus

on the more tangible risk the person staying in the home may bring. This

raises the concern that the CSC professionals, including the chair of the

strategy meeting, did not at that time have the knowledge and experience to

recognise all aspects of the risks for these children. A contributory factor was

that the staff were working within a system that, at the time, did not recognise

the serious risk that physical and emotional neglect poses to children. The

schools were not at the meeting as it was held in the summer holidays.

8.50 The GP Agency Report states that there was a pattern of delaying responses

in this case, for example the delay in pulling together meetings, even as late

as the meeting held just days before Abigail was admitted to hospital. ‘This

appears to be because of the feeling, with this family, that the concerns at the

time were just more of the same.’

8.51 The Hospital Agency Report author points out that the Health Visitor was

signalling indicators of severe failure to thrive, but that Abigail did not get the

hospital assessment required due to the GP giving the hospital doctor

reassurance about Abigail’s well-being.

8.52 All schools felt there needed to be more clarity about the thresholds for

neglect. They acknowledged however that recently there has been a Levels

of Intervention document shared which helps, and neglect workshops run

throughout the county. (See below.)

8.53 CSC reports that at the time of the first two key practice episodes, the culture

that existed about neglect in the organisation was unhelpful for these children.

Understanding about the serious long-term effects of neglect were not clear,

and it was very difficult to get neglect cases into legal proceedings. As

recently as November 2012 it took the critical incident, of Abigail’s nappy rash

and severe malnourishment, to ensure her removal from the family.

8.54 Lesson 8

Staff across all agencies must have a shared understanding of neglect and its

impact on the safety, wellbeing and development of children. All professionals

40

working with children should be trained and supported in regards to

recognising child neglect, and be provided with the tools to work effectively

with children and families where there are concerns about neglect. This

includes a focus on building a shared understanding of the children’s history

by incorporating all of the information held on the family across the agencies

involved.

Recommendation 5

That GSCB review their neglect training to ensure that it has improved the

shared understanding of neglect across agencies. This review should include

a request that all agencies review professional training and qualification

courses locally to ensure they include training on child development and the

impact of neglect.

9 Conclusions and lessons learned

9.1 As stated by the author of the Hospital Agency Report ‘the child subjects of

this report experienced chronic neglect of basic nutrition, of

developmental/learning opportunity, and of emotional development whilst

living within the family home in the responsible care of their parents’.

9.2 The study ‘Working with Neglected Children and their Families: Linking

Interventions With Long-term Outcomes’ (Farmer and Lutman 2012)

considers the processes that are likely to affect the longer-term management

of families where there are neglect issues.

They are:

• Becoming de-sensitised to children’s difficulties through habituation when

undertaking medium- to long-term work

• Normalising and minimising abuse and neglect

• Downgrading the importance of referrals about abuse or neglect from

neighbours or relatives

• Over-identification with parents

• Developing a fixed view of cases which discounts contrary information.

• Viewing each incident of neglect or abuse in isolation and not recognising

their cumulative impact

The majority of these factors influenced the on-going work with the family. It is

in many ways a classic neglect case. However the family were provided with

41

preventative interventions and early help strategies for a number of years,

rather than working with them under a clear, robust and time bound plan that

recognised and met the children’s needs, and used a child protection remit as

required.

9.3 Children’s services in Gloucestershire have had to improve their safeguarding

services after concerns were identified during an Ofsted inspection in 2011,

which was when the serious concerns about Abigail were emerging. A follow

up inspection in March 2012 found improvements had been made. The review

was provided with information to show the relevant improvements. They

include:

GSCB provided a Neglect Workshop for partner agencies in March-April

2013. It was attended by staff from schools and colleges, early years,

children centres, all health providers, Police, Probation, children’s social

care, as well as a number of voluntary sector providers.

CSC devised and published their ‘Standards with Timeline for children in

need from the point of transfer to the Child and Families Teams’ in 2013.

The aim is to ensure more robust work with and oversight of child in need

plans.

CSC appointed an independent child protection consultant to provide a

neglect presentation and a neglect findings report in 2013. Each team also

received a neglect research papers file to supplement the presentation.

GSCB has overseen the rolling out of multi-agency professional reflective

meetings from April 2013, which take place when a child has been subject

to a CP Plan for over 12 months. Although it would not have assisted in

this case, it should assist in the development of good practice across

agencies. The awareness of and benefit of this model will be explored with

partner agencies in the Section 11 audit that Gloucestershire are

undertaking in the autumn of 2013.

9.4 Two recent ‘Learning Together’ reviews have been undertaken in

Gloucestershire using the SCIE systems model, firstly in 2012 and then in

March 2013. This review has heard that a number of the issues identified in

that review have also been noted here. The findings from the 2012 review

included:

42

- Managers to use Safeguarding Practice Reflection. This should be

used for all staff working with families across all setting.

- Keep Chronologies for children and young people. Record the

significant events for your families and include any actions taken and

outcomes. Multi-agency chronologies can easily be collated, they also

assist with identifying needs, patterns and clear working strategies.

Chronologies should be brought to multi-agency meetings to help

inform interventions and assessments.

The findings in the second review included:

- A pattern of significant professional activity but little collaboration or

challenge across agencies raises questions about what working together

actually means in Gloucestershire.

- In Gloucestershire there is a pattern of focussing on the tool (e.g. the Plan

for the child) rather than the impact that the content has had on the child’s

journey.

9.5 The CSC Agency Report provided helpful information in respect of progress in

their systems and auditing in response this child’s case, and others identified

during the OFSTED inspections and other reviews undertaken. These include

improving children’s assessments and plans by implementing a Framework

for Thinking. There remains work to do, but they are committed to embed the

system across all teams. There are also improved auditing schedules, both

single and multi-agency.

9.6 In January 2014, Ofsted undertook a thematic inspection of Early Help in

Gloucestershire. It found that within the early help cases, children’s voices

were heard and the professionals know the children well. As a result of well

coordinated early help work by professionals, the children and families were

well engaged. There was positive feedback to Referral & Assessment teams

for the advice they give to partners. Inspectors cited some specific good

practice in coordinated services for children needing early help, including the

Journey into Positive Parenting (JIPP) programme, Targeted Support Teams

and Integrated Youth Services. This shows there have been positive

improvements since the children in this case were referred into the system.

43

9.7 The reason for undertaking this review is to learn lessons. The Reviewers

have been impressed by the commitment to this process shown by the staff of

the partner agencies of the GSCB. In the Agency reports the terms of

reference have been addressed, and the lessons for the agency have been

identified, and recommendations made.

9.8 The lessons learned for the GSCB and inter-agency practice have been

identified in the analysis above, they are :

Lesson 1

Professionals in the agencies involved in this case had difficulties in keeping a

clear focus on the needs of the children, due to the need to negotiate the

many demands and difficulties of the parents. Supervision needs to play a

clear role in ensuring that assessments, plans and interventions listen to the

child’s voice and consider this information when taking actions. To quote

Working Together 2013 ‘Ultimately, effective safeguarding of children can only

be achieved by putting children at the centre of the system, and by every

individual and agency playing their full part, working together to meet the

needs of our most vulnerable children.’

Lesson 2

The child’s experiences should be at the heart of all plans. Robust, time

bound and outcome focused plans need to be in place for all children where

there are concerns about the capacity or motivation of the parents to improve

the children’s circumstances. These plans should include extended family

members.

Lesson 3

The following issues remain of concern and require a clear message to all

agencies:

- The need for clarity regarding sharing information on children and their

siblings and parents, when they are not identified as a ‘child protection

case’.

- The need for clarity about the option of holding professionals meetings

without the parents attending, which may have been useful in this case.

- The need for clarity regarding the ability of all agencies to request a

strategy meeting.

44

Lesson 4

It is the robustness of the plan, which must include a contingency plan and the

involvement of all agencies and the family, which will ensure the needs of the

children are assessed and met. Not the status of that plan. In this case it is

clear that the plan should have made it clear that if the parents did not

cooperate fully with what was required to ensure the children’s needs were

met, that legal advice would be sought.

Lesson 5

All assessments of risk should consider and analyse the historical information

held across agencies.

Lesson 6

All professionals working with children and families need to be trained and

supported, to include the provision of reflective supervision, in the

identification and challenge of parents who use manipulation and disguised

compliance, to ensure the needs of the child remain the priority.

Lesson 7

All agencies need to have the confidence to challenge or question decisions

taken by other professionals in partner agencies. Clear guidelines and

training, supported by supervision, needs to give professionals the confidence

to challenge each other and to escalate any concerns they have via the

resolution policy. The review has heard that agencies defer to Social Care

when it comes to decisions about the need for services to be provided to

children in need and in need of protection. GSCB need to ensure that they

advertise the message, including in training, that professional disagreement is

a positive sign of a healthy safeguarding system.

Lesson 8

Staff across all agencies must have a shared understanding of neglect and its

impact on the safety, wellbeing and development of children. All professionals

working with children should be trained and supported in regards to

recognising child neglect, and be provided with the tools to work effectively

with children and families where there are concerns about neglect. This

includes a focus on building a shared understanding of the children’s history

45

by incorporating all of the information held on the family across the agencies

involved.

Good Practice and systems that worked well

9.9 It was clear that a number of professionals provided the children and family

with a high level of support and assistance. This should not be lost in the

analysis of why things went wrong. The family had good consistency of care

from health and education professionals, who provided extra support and

services to the family for many years, this included the Children’s Centre, the

Health Visitors, the GP and the schools. All undertook regular home visits.

Both Health Visitors showed persistence in getting access to the house when

appointments were regularly missed.

9.10 There were examples of CSC visiting with other professionals, particularly the

Health Visitors, in both the first and last key practice episodes.

9.11 When meetings were held, they were very well attended. Whatever the status

of the meeting, those that were invited attended. This reflects the amount of

concern in the professional network, but also the strong commitment to the

children.

9.12 Professional challenge was evident from the schools and the Health Visitors

in particular, but also from doctors in primary and secondary care.

9.13 The three schools talked to each other regularly. Information on the children

was transferred appropriately at transition and there was a good

understanding of the challenges the children faced from their peers due to

their problems.

9.14 Since the children were removed from their parents care the Local Authority

has been proactive in placing them and getting appropriate orders to ensure

their future. The children are reported to be settling well in their current

placements, and are receiving help to recover both physically and emotionally

from the significant harm they have endured.

46

10 Recommendations

10.1 Each agency report submitted to this review has included reflection on its

individual learning, and made recommendations that are agency specific. The

lead reviewers welcome this and recommend they are followed through and

that progress is reported to the GSCB.

10.2 Listed below are the recommendations from this overview report.

Recommendation 1:

GSCB to undertake an audit of assessments and of child in need and child

protection plans to ensure that the child’s voice has been heard and is taken

into account in the conclusion of the assessment and throughout the plan.

Recommendation 2:

The GSCB should support a framework of meetings which allow professionals

involved in particular cases to meet and reflect on professional dynamics and

disagreements without the presence of children and families.

Recommendation 3:

That the GSCB review its model of reflective supervision, to ensure that it is fit

for purpose in assisting professionals to gain confidence in working with

parents who are manipulative and show disguised compliance. Consideration

is to be given to using this model with more complex Child in Need cases, as

well as those subject to a Child Protection plan.

Recommendation 4:

That the GSCB’s new Levels of Intervention model includes a clear link to the

professional challenge policy, and is clear that requests for explanations of

why decision have been made should be sought as applicable.

Recommendation 5:

That GSCB review their neglect training to ensure that it has improved the

shared understanding of neglect across agencies. This review should include

a request that all agencies review professional training and qualification

courses locally to ensure they include training on child development and the

impact of neglect.

47

………………………..

48

Bibliography

Ofsted

Learning lessons from serious case reviews, year 2

October 2009

Ofsted The voice of the child: learning lessons from serious case reviews April 2011 Ward, H, Brown, R, Westlake, D Safeguarding Babies and Very Young Children from Abuse and Neglect 2012 Action for Children State of child neglect in the UK 2013 Farmer, E, and Lutman, E Working with Neglected Children and their Families: Linking Interventions With Long-term Outcomes 2012 Brandon M et al The Biennial Analysis of Serious Case Reviews 2003-2005 DCFS 2008

49

Appendix 1 – Terms of Reference and Project Plan

SCOPE

The subject child and where appropriate her three other siblings, during the period between

August 2010 (strategy discussion) to 23rd November 2012 (admission to hospital).

FRAMEWORK

Serious Case Reviews and other case reviews should be conducted in a way in which :

Recognises the complex circumstances in which professionals work together to

safeguard children;

Seeks to understand precisely who did what and the underlying reasons that led

individuals and organisations to act as they did;

Seeks to understand practice from the viewpoint of the individuals and organisations

involved at the time rather than using hindsight;

Is transparent about the way data is collected and analysed; and

Makes use of relevant research and case evidence to inform the findings

(Working Together para 10, March 2013)

AGENCY REPORTS TO BE COMMISSIONED

1. GP

2. School Nurse and Health Visiting

3. Education/Early Years/Children’s Centre

4. Children’s Social Care

5. Police

6. Hospitals Trust Gloucestershire (Midwifery and Paediatrics)

TERMS OF REFERENCE

Individual agency reports need to consider

1. The quality of risk assessment and how the levels of need / harm were assessed by

individual agencies.

2. The individual agency reports need to encompass a view as to how an analysis of

historical information was used to inform assessment and decision making and

evidence of use of a chronology of key events.

3. The culture and approach of each agency (collective if more than one team / school

involved) and individual within the agencies towards neglect.

4. Whether professional differences occurred and if so how they were responded to.

50

5. The level and quality of partnership working when the lead professional role was

held in the community.

6. The level and quality of partnership working when social care were the lead agency.

7. The timeliness of responses by professionals (internal and external to the agency

report) to issues raised.

8. To identify and include areas of good practice within each agency

A TEMPLATE FOR AGENCY REPORTS

Attached

TIMETABLE

Scoping / terms of reference 23 April

Commissioning letters 3 May

Authors Briefing 17 May

Distribution of material to all attendees 9 August

Learning Event 9 September

Drafting 1st report and distribution 3 October

Recall Day 10 October

Revising Report 17 October

Presentation to LSCB/SCR Sub group 23 October

Meetings with Family/Significant Others

Explanation of Process 10 May

Feedback re: experience of services 10 June

Discussion of final report 23 October

Appendix 2 – Template for Agency Report

51

AGENCY REPORT (name of agency)

SIGNIFICANT INCIDENT LEARNING PROCESS

SUBJECT :

BORN :

Name of author

Job title

Date

INTRODUCTION

52

PURPOSE

Previous statutory guidance suggests the purpose of a serious case review is :

To establish what lessons are to be learned from the case about the way in which

local professionals and organisations work individually and together to safeguard

and promote the welfare of children

To identify clearly what those lessons are both within and between agencies, how

and within what timescales they will be acted on, and what is expected to change as

a result; and

Improve intra- and inter-agency working and better safeguard and promote the

welfare of children

(Working Together para 8.5, March 2010)

FRAMEWORK

Serious Case Reviews and other case reviews should be conducted in a way in which:

Recognises the complex circumstances in which professionals work together to

safeguard children;

Seeks to understand precisely who did what and the underlying reasons that led

individuals and organisations to act as they did;

Seeks to understand practice from the viewpoint of the individuals and organisation

involved at the time rather than using hindsight;

Is transparent about the way data is collected and analysed; and

Makes use of relevant research and case evidence to inform the findings

(Working Together para 10, March 2013)

SCOPE

53

The subject child and where appropriate her three other siblings, during the period between

August 2010 (strategy discussion) to 23rd November 2012 (admission to hospital).

Section 1 – Summary of Facts

a. Summarise in narrative form the key information relating to W from your

agency/service.

b. Summarise the services offered and / or provided to her and/or the decisions

reached.

Section 2 – Other Relevant Information

a. Report any significant information prior to December 2010 which you consider to be

relevant to the learning.

Section 3 – Analysis

a. Critically analyse and evaluate the events that occurred, the decisions made and

the actions taken or not.

b. Where judgements were made or actions taken which indicate that practice or

management could be improved, try to get an understanding not only of what

happened, but why.

c. Demonstrate whether your agency/service heard and responded to X’s views, wishes

and feelings.

d. Identify and explain if your agency/service believes that other agencies/services should

have been sought and /or provided.

You may find the 12 trigger questions from previous statutory guidance (para 8.39 of Working

Together 2010) helpful in framing your response. However, it is not expected that you methodically

answer every question. Use it as a guide.

These questions are attached as appendix 1.

Section 4 – Terms of Reference

Individual agency reports need to consider

1. The quality of risk assessment and how the levels of need / harm were assessed by

individual agencies.

54

2. The individual agency reports need to encompass a view as to how an analysis of

historical information was used to inform assessment and decision making and

evidence of use of a chronology of key events.

3. The culture and approach of each agency (collective if more than one team / school

involved) and individual within the agencies towards neglect.

4. Whether professional differences occurred and if so how they were responded to.

5. The level and quality of partnership working when the lead professional role was

held in the community.

6. The level and quality of partnership working when social care were the lead agency.

7. The timeliness of responses by professionals (internal and external to the agency

report) to issues raised.

8. To identify and include areas of good practice within each agency

Section 5 – Conclusions and Recommendations

In your conclusion please consider learning for your agency and multi agency

learning as separate issues. Highlight strengths as well as weaknesses. Consider how

you will recommend improvements may be made to services, ie

What action should be taken by whom and when?

What outcomes should these actions bring, and in what timescales, and

How will the organisation evaluate whether they have been achieved?

Single agency recommendations should be brought into the overview report

and Questions here should be more positive to promote good practice e.g.

where was good practice identified?

APPENDIX 1

a. Were practitioners aware of and sensitive to the needs of the children in their

work, and knowledgeable both about potential indicators of abuse or neglect

and about what to do if they had concerns about a child’s welfare?

b. When, and in what way, were the child(ren)’s wishes and feelings ascertained

and taken account of when making decisions about the provision of children’s

services? Was this information recorded?

c. Did the organisation have in place policies and procedures for safeguarding

and promoting the welfare of children and acting on concerns about their

welfare?

55

d. What were the key relevant points/opportunities for assessment and decision

making in this case in relation to the child and family? Do assessments and

decisions appear to have been reached in an informed and professional way?

e. Did actions accord with assessments and decisions made? Were appropriate

services offered/provided, or relevant enquiries made, in the light of

assessments?

f. Were there any issues, in communication, information sharing or service

delivery, between those with responsibilities for work during normal office

hours and others providing out of hours services?

g. Where relevant, were appropriate child protection or care plans in place, and

child protection and/or looked after reviewing processes complied with?

h. Was practice sensitive to the racial, cultural, linguistic and religious identity and

any issues of disability of the child and family, and were they explored and

recorded?

i. Were senior managers or other organisations and professionals involved at

points in the case where they should have been?

j. Was the work in this case consistent with each organisation’s and the LSCB’s

policy and procedures for safeguarding and promoting the welfare of children,

and with wider professional standards?

k. Were there organisational difficulties being experienced within or between

agencies? Were these due to a lack of capacity in one or more organisations?

l. Was there an adequate number of staff in post? Did any resourcing issues such

as vacant posts or staff on sick leave have an impact on the case?

m. Was there sufficient management accountability for decision making?

56

GLOUCESTERSHIRE SAFEGUARDING CHILDREN BOARD

SUBJECTS

Abigail and her siblings Bobbie, Charlie and Daisy

Overview Report – Additional Section

Author: Janice Waters MSc Registered Nurse

Specialist Nurse Safeguarding

12th August 2014

57

CONTENTS

Section Topic Page

1 Introduction and rationale for the report 58

2 Methodology 59

3 The new information

61

4 Summary of sentencing comments

62

4a Peaks and Troughs

62

4b Not a case of deliberate behaviour

62

4c Physical disabilities

63

5 Summary of Psychotherapist’s feedback

63

5a Powerful personality disorder

64

5b Professional splitting

64

5c Systemic paralysis

65

5d Challenges

66

6 Summary of further information from Housing

66

6a Record keeping

66

6b Accessing the home

67

6c Challenges

67

7 Summary of the Practitioner Learning Event

68-70

8 Conclusion 71

References 72

Appendix 73

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1. Introduction

Working Together 2013 (Department for Education 2013) states that serious case reviews

(SCR) of incidents involving children should be conducted in a way that

Recognises the complex circumstances in which professionals work together to

safeguard children.

Seeks to understand precisely who did what and the underlying reasons that led

individuals and organisations to act as they did.

Seeks to understand practice from the viewpoint of the individuals and

organisations involved at the time rather than using hindsight.

Is transparent about the way data is collected and analysed.

Uses relevant research and case evidence to inform the findings.

With this in mind, a serious case review was undertaken through a SILP review process.

Following the court proceedings, further work has been undertaken in a way that ensures

these principles have been followed, including a multi agency Practitioners Learning Event.

This additional section records the findings of this further work.

Rationale for the report As was anticipated, other significant information about the family came to light during the

court process in respect of the parents of Abigail and her siblings Bobbie, Charlie and Daisy.

The additional information has emerged from 3 sources

The sentencing remarks during the criminal proceedings (16th June 2014)

The report of the Psychotherapist (30th June 2014)

Additional views sought from Stroud District Housing (2nd July 2014)

In keeping with the SILP report, and the methodology of this additional section, a follow up

Practitioner Learning Event was held on the 4th July 2014 to uncover any new learning from

the new information. Abigail’s parents declined the offer to take part in any discussion at this

time. The PLE was found to be especially powerful in supporting practitioners to effectively

collaborate in the process of learning and analysis and to this end Gloucestershire

Safeguarding Children Board (GSCB) would like to thank those taking part for their timely

and effective contribution to the process.

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This additional review does make further recommendations; the additional Practitioner

Learning Event (PLE) has confirmed support for the recommendations made. Professionals

felt the value of their additional discussions would be best reflected by identifying the key

issues that the safeguarding board should consider. It is for this reason that this additional

section will pose a series of challenges to the Gloucestershire Safeguarding Children Board

(GSCB) rather than the setting out of specific recommendations. This is in line with serious

case reviews produced nationally using the systems methodology that has also informed this

case review.

This section will therefore

Focus on practitioner reflections at the learning event of the new information that

emerged as a result of the court process.

Take the opportunity for further reflection on practice in the 6 months leading up to

the parents’ arrest on 24th Jan 2013.

Reflect on what has changed since that time.

2. Methodology

The methodology for this additional work is taken from ‘Systems analysis of clinical

incidents: The London protocol’ (Taylor-Adams et al. 2004). This system is based upon

James Reason’s ‘Swiss Cheese model’ of accident causation used in risk analysis and

management in systems such as aviation, engineering and healthcare (Reason 2000). The

model likens human systems to multiple slices of Swiss cheese stacked side by side and is

sometimes called the cumulative act effect. The Swiss cheese model of accident causation

illustrates that although many layers of defence lie between hazards and accidents, there

are flaws in each layer that, if aligned, can allow the accident or incident to occur

Taylor-Adams’ and Vincent’s protocol provides a structured, systems approach to the

process of learning from incidents in health care settings, providing a “window on the

system”. Examples of their work have been adapted in various ways to support

investigations outside healthcare, for example by the Social Care Institute for Excellence

(SCIE). The purpose of the protocol is to ensure both a comprehensive and a thoughtful

investigation of an incident and to move practitioners beyond the identification of fault and

blame. Thus, a structured approach to the use of practitioner reflection has been found to be

successful in utilising clinical experience and expertise to its fullest extent.

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This approach is reported by Taylor-Adams and Vincent to assist the reflective investigation

process, because:

‘While it is sometimes straightforward to identify a particular action or omission as the

immediate cause of an incident, closer analysis usually reveals a series of events

leading up to adverse outcome. The identification of an obvious departure from good

practice is usually only the first step of an investigation’.

‘A structured and systematic approach means that the ground to be covered in any

investigation is, to a significant extent, already mapped out. This guide can help to

ensure a comprehensive investigation and facilitate the production of formal reports

when needed’.

‘If a consistent approach to investigation is used, members of staff who are

interviewed will find the process less threatening than traditional unstructured

approaches.’

‘The methods used are designed to promote a greater climate of openness and to

move away from finger pointing and the routine assignation of blame.’ (The London

Protocol)

This methodology supports the inclusion of ‘contributory factors’ adapted from the London

Protocol, using the notion of holes or weaknesses identified in James Reason’s ‘Swiss

cheese’ model. Contributory factors are deemed to be features that reveal examples of

either good practice or practice that could be improved.

Contributory Factors

Child or family factors; examples of which may include;

Complexity of the problem(s)

Personality and social factors

Manner of presentation, language and communication – relationship with

professional(s) - seeking help, hostility, disguised compliance, impact on

professionals and how they worked together

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Task and technology factors; examples of which may include;

Understanding nature of task – e.g. waiting for serious incident, or gathering a

cumulative picture?

Decision making aids utilised (or not)

Availability and use of protocols

Frontline Professional factors; examples of which may include;

Knowledge, skills, competence

Human reasoning

Communication/Information sharing

Managerial support/Supervision

Clarity of roles between professionals

Attention (what were the professionals focussing on, the same, or different things?)

Culture of dealing with disagreement – was it explicit or covert?

Organisational and management factors; examples of which may include;

Organisational priorities, structures, cultures – either single, or multi-agency

Thresholds, application of local policy & procedures

Availability of or gaps in services e.g. expert assessment on personality/capacity to

change?

National level factors; examples of which may include;

Statutory policy e.g. on information sharing, is this a help or hindrance?

Tools: assessment, risk management

Links with external organisations

An interaction matrix is available in the appendix and offers a visual interpretation of the

contributory factors drawn out at the Practitioner Learning Event (Appendix 1).

3. The new information

This section will consider in turn, the summaries of

The sentencing remarks

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The Psychotherapist’s feedback

The housing information

Within each summary, consideration will be given to the influencing contributory factors, the

response of the practitioners at the learning event to the new information and any learning

and challenges which were highlighted.

4. Summary of the sentencing remarks

The main points that professionals reflected on in relation to sentencing remarks relate to

‘Peaks and Troughs’ in episodes of neglect throughout the years

Reference to this not being a case of ‘deliberate behaviour’

The presence of physical disabilities for both parents.

4a: Peaks and Troughs (Child and family factor)

Peaks and troughs in episodes of neglect were highlighted in the sentencing remarks.

Whilst there were undoubtedly times when care of the children appeared to improve, the

phrase ‘peaks and troughs’ used by the Judge was reflected on by professionals who

worked with the family in the context of ‘Disguised Compliance’. This means a situation

which poses difficulties for professionals working with families and involves the parent or

carer giving the impression of co-operating with services in order to diffuse professional

intervention.

The term, disguised compliance is attributed to Reder, Duncan and Gray in ‘Beyond blame:

child abuse tragedies revisited’ (Reder P et al. 1993). The effect of disguised compliance is

to neutralise the authority of the professional, examples of which occur in this case in the

sporadic attempts at increased school attendance, attending medical appointments,

engagement with professionals for a limited time or the cleaning of the home prior to visits by

professionals.

4b: Not a case of deliberate behaviour (Child and family factor)

Sentencing highlighted that this was not a case of deliberate behaviour but stated that the

parents were ‘inadequate, stupid, stubborn, incompetent but not wicked’.

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Practitioners at the learning event reflected on the parents’ stubbornness in not responding

to professional advice and felt that, on occasions, they exhibited disguised compliance.

Examples of this were cited as when the prescribed cream for Abigail’s nappy rash had been

squeezed out so as to appear that it had been used and another occasion when it was

hidden from view during a professional visit. On other occasions, the cream was used to

reinforce a sense of compliance with professionals in an aim to reassure them that the

nappy rash was being treated. Professionals at the learning event were clear that Abigail’s

mother was resistant to following advice given by them.

4c: Physical disabilities (child and family factor)

The physical disabilities of both parents were referred to in the sentencing remarks. The

children’s parents both had health and psychological problems of their own, which

demanded a lot of professional attention. Practitioners at the learning event confirmed that

there was no clear evidence of physical disabilities being the reason for neglect of the

children, but rather a case of the parents placing of their own needs above those of the

children. This led the PLE to reflect further on incidents where parents appeared to prioritise

their own needs;

One example includes the number of GP appointments that the parents attended; a total of

100 appointments are recorded during the period for the parents whereas there are just 40

for children despite the number of children involved, the nappy rash, a diagnosis of anaemia

and the hospital admissions.

Further examples of parental need above that of the children includes the parents taking a

holiday which was longer than had originally been planned and stating that they had taken

the nappy rash cream with them, but in fact did not. Practitioners at the learning event

reported that Abigail’s mother had told them they had never had a honeymoon and that it

was their right to do so.

5. Summary of the Psychotherapist’s feedback

The main points to be discussed within the Psychotherapist feedback relate to

Powerful personality disorder

Professional splitting

Systemic Paralysis

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5a: Powerful personality disorder (Child or family factor)

The Psychotherapist and her colleagues, working in a separate capacity with a member of

the family, made contact with the review team as a result of the family court case.

The Psychotherapist recognised within Abigail’s mother a ‘diagnosable and powerful

personality disturbance’. She reports a very clear view about the power of Abigail’s mother

as a personality who continually interrupted the interview process with her daughter and who

could not prioritise her children’s needs above her own. An example given was an incident

where the older daughter understood that her baby’s nappy needed changing but appeared

to wait for her mother to give her permission to do so.

Abigail’s mother was reported to be open and confident in revealing to the Psychotherapist

and others that she had been advised to admit Abigail to hospital but had gone against this

advice. She described herself as a busy mother who loved her children very much. This

confidence was further evidenced by not hiding the nappy rash from the visitors in the

house, professionals at the learning event queried whether this was an opportunistic or

purposeful act.

Abigail’s Grandmother was reported to have been wary of upsetting her daughter for fear of

being excluded from the care of the children.

5b: Professional Splitting (Frontline professional factor)

The powerful personality displayed by Abigail’s mother appeared to give her the opportunity

to divide professional opinion between the Psychotherapist and her colleagues. This was

described as a case of ‘professional splitting’ (Melia et al. 1999). Melia et al described

professional splitting as the ability to divide loyalties amongst professionals by comparing

and complaining about one with another.

Abigail’s mother was reported to have the ability to ‘literally fill the room’ and that by doing so

was able to divide opinions amongst the Psychotherapist and colleagues, thereby ‘splitting

the group’. This resulted in one half of the group reporting that the state of the home and the

presentation of the child was ‘none of the their business’ and the other half reporting that

‘serious risk issues were being identified’.

Practitioners at the learning event reflected on this additional information from the

Psychotherapist and discussed the comments about ‘professional splitting’ in the context of

their own experience of the parent’s complaints about one organisation to another. Abigail’s

mother was described as being able to influence others, for example the children’s

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hairdresser who was persuaded to write a letter to health services to say that the children

didn’t have head lice when evidence pointed otherwise.

Child protection thresholds were viewed as having been reached by some professional

groups but not all. This allowed the parents to split professional opinion and resulted on one

occasion in Abigail not being admitted to hospital for treatment of her nappy rash.

Recognition of ‘professional splitting’ is an example of good practice and could be improved

through the sharing of information that recognises the difficulties faced by professionals

when dealing with families who criticise professionals and organisations.

5c: Systemic Paralysis (Frontline professional and organisational contributory factor)

The Psychotherapist revealed discussions held with colleagues about the filthy state of

Abigail’s home and describes the smell emanating from the family and the malnourished

appearance of Abigail, who at 3 years old was still in nappies. These were described as

serious safeguarding concerns by some, but not all of her colleagues.

In light of her concerns, the Psychotherapist reports that she made numerous attempts to

contact Children’s Social Care (CSC) but was not able to speak with a social worker for a

couple of weeks due to a number of missed attempts at contact by both parties. She

questions that in her opinion, whether a ‘systemic paralysis’ was in evidence. By this time

CSC were conducting their own investigations and did not view this information as

warranting immediate, additional action.

Systemic paralysis is described as the act of professionals unconsciously colluding with a

parent’s denial of a given situation and themselves becoming at risk of using the same

defensive processes as the parents. Practitioners at the learning event reflected upon this

statement but did not agree with the Psychotherapists findings. Practitioners at the learning

event questioned why the Psychotherapist did not follow up their concerns with a letter or

escalate to the manager of the team is there was no response from the social worker.

The Team Manager of the team was not aware that this professional had been unable to

speak with the social worker so had not been in a position to intervene. The social worker in

question was not part of the review as they no longer work for the local authority.

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5d: Challenges

The following reflections and challenges for local services are provided in relation to the

information above and placed within the context of systems learning.

Should further training be developed for professionals to enable them to remain

focused on the purpose of a home visit and take the lead in the conversation rather

than following the lead of the parents or carers?

Is there sufficient understanding of the concept of ‘professional splitting’ across

partners?

Are professionals across the child protection system able to recognise when

systemic paralysis may be occurring?

Should training be made available to assist professionals to recognise the symptoms

of professional splitting and systemic paralysis?

6. Summary of further information from Housing

The main points from the Housing related to

Record keeping

Access to the home

The feedback from the Housing Department at Stroud District Council (SDC) informed the

further PLE that they were not aware of any concerns from a housing perspective, apart from

the use of a wood burning fire in the property, which is not an issue related to the neglect of

children. Reassurance has been given that all staff members undertake training in

safeguarding and are aware of the need to report concerns with to the lead safeguarding

officer. It is good practice that staff are all trained in safeguarding, but another perspective

on the family might have been gained if they had been more involved at the time.

6a: Record keeping (Frontline professional factor and organisational factor)

The family was noted to be difficult to contact and records suggest that, therefore

correspondence tended to be by letter.

The housing officer involved at the time of the issues raised by the SCR is reported to be no

longer employed at SDC and therefore clarity is being sought by them as to whether or not

contact was made with the family but not entered into the case notes. If so, an individual

management review will be recommended.

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6b: Accessing the home (Task and frontline professional factor)

Factors relating to the child and family are apparent in the difficulty experienced by the

housing officer in accessing the house.

The difficulties experienced by other professionals, for example hostility and a lack of

cooperation may have also been experienced by the officer working with this family.

Opportunities to engage with other professionals were unfortunately not identified and may

therefore have been missed.

Right of entry could have aided this case, for example during gas and heating boiler checks.

This may have assisted housing officers in accessing the home perhaps in conjunction with

other professionals and therefore represents a missed opportunity to intervene in the welfare

of the children.

The photographs picturing ivy in one of the children’s bedroom were used by the police

during the court case to convey the state of the house and were reflected upon during the

practitioner learning event. It was confirmed that these were taken 2 months after the

children had left the home and did not represent how workers saw the home while the

children were actually living in it.

6c: Challenges

Is the importance of the role of housing recognised in child protection work locally?

How do we ensure there is a better understanding of ‘right of access’ in respect of

the condition of homes owned by LAs or social landlords?

How do we enhance the understanding of housing professionals of the impact of

housing conditions on families e.g. on a child’s education?

How can we progress collaborative working with Housing professionals and should

the model of basing family support staff within Housing agencies operating within

Families First be replicated?

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7. Practitioner Learning Event: What we are doing differently

As the majority of the responses to the new information are contained within each of the

preceding sections, this section highlights the remaining areas of conversation during the

practice learning event and highlights what Gloucestershire are already doing differently.

A: Healthy challenge involves checking, clarification, being inquisitive and asking

the question why. The safeguarding system does not exist without healthy challenge.

Healthy challenge has taught us to be aware that just because parents say

something it doesn’t mean that it is happening.

Some professionals and individual agencies felt that they don’t always have the

information to be able to challenge because parents or carers don’t always wish to

share information and as a result do not give consent to do so. School practitioners

reported that they were not always able to exercise healthy challenge at the level of

‘child in need’ section 17 Children Act 1989 enquiries (s.17) as experienced in this

case where Abigail’s mother did not consent for the school to receive the report.

A better understanding across agencies now exists of when the threshold of child

protection is met and a strategy discussion needed as opposed to when a multi-

agency meeting is required.

B: At the time of the case, agencies felt although they might share information they

would not always get something back. Working with neglect requires proper

information sharing across agencies which is less straightforward than it might

appear. When working with a Child in Need under section 17 of the Children Act,

parental consent to share information is vital. This meant professionals working with

Abigail were not necessarily free to gather information from all professionals to

identify whether this revealed persistent neglect, as the parents withheld consent for

information to be shared between all agencies. Social Workers in the case were

particularly mindful of the judicial risks of escalating enquiries to child protection level

and the full sharing of information without enough supporting evidence to do so. This

is an area under scrutiny by the GSCB as part of the MASH (Multi-agency

Safeguarding Hub). Social care reflected that it is rare that a parent refuses consent

to share information and when they do their parental rights are respected, but the

reasons why they might be withholding consent need to be robustly considered.

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C: Professionals agreed that the assessment under the Common Assessment

Framework (CAF) was not robust in that it wasn’t child focussed, was inadequately

monitored and wasn’t multi-agency. Professionals discussed the robustness of the

plan and recognised that this is what is important. The level of the plan, whether it is

a CAF (Common Assessment Framework), CiN (Child in Need) or CPP (Child

Protection Plan) isn’t what makes the plan ‘right’. It is about the plan being able to

meet the needs and hearing the voice of the child.

This ‘culture of practice’ has moved on and professionals now consider more closely

the impact of the plan for the child with a clear contingency plan in place. Plans are

tighter and time limited. Police will be involved in the process sooner.

D: There was recognition of the fear of family disengagement within the group and

a discussion of how organisations made attempts to keep children safe. For example,

schools report achieving this by placing importance on being able to see children at

school on a daily basis.

E: Frustration amongst practitioners was evident in the response to Children’s

Social Care who they felt had not always responded adequately to the situation of

children in this family historically. CSC confirmed that they had made unannounced

visits to the family which did not raise concerns for them and at times what was

observed in the family home appeared to invalidate the concerns about neglect that

were being reported by professionals.

F: In this case the parents were difficult to work with. Professionals were trying to

work with them and not allow a breakdown of the professional relationship due to the

fear of family disengagement and not being able to keep the children safe is very

powerful. Abigail’s mother was discussed as being extremely manipulative with the

ability to isolate professionals. Practitioners at the learning event discussed how

practice has improved and they would now have a better understanding of the history

of the families they are working with.

G: Practitioners at the learning event reported that sometimes their experience is that

the rights of the parent seem paramount to the rights of the child and at the time of

this case, this was thought to be so.

Of course this will always be an area where a balance needs to be maintained. There

is now an emphasis on seeing children as individuals in their own right who are

encouraged to express their opinions, wishes and desires.

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H: Agency drop off was discussed and described as the experience of Children’s

Social Care (CSC). This means that once a referral has been accepted by CSC then

other agencies expect them to take the lead whilst the continued involvement and

engagement from key professionals is vital to protect children. Agencies were

encouraged to maintain their involvement.

Challenges

Should the GSCB provide more information and training on how to deal with families

who employ disguised compliance?

Peaks and troughs were observed in this case, a better understanding of the long

term impact of neglect demands a long term perspective in understanding whether

families are able to make sustained improvements. How can the GSCB promote

good planning and clear milestones?

Are professionals now better able to balance conflicting needs within families so that

parents needs do not take priority over the needs of the children?

Are we confident that practitioners respect each other’s views regarding thresholds

and avoid unintentionally colluding with challenging families?

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Conclusion

The new information that has now become available in this case suggests that the

contributory factors are predominantly associated with the child and family (Appendix 1). It is

likely that these factors caused problems for frontline professionals who felt the full force of

the difficulties associated with working with this family. Systemic paralysis, if indeed it exists,

in combination with a lack of robust planning, feature as organisational contributory factors.

Professionals at the learning event were able to confidently identify areas of improvement

and ‘moving on’ in order to give reassurance for future practice. Training on the importance

of neglect has been rolled out across the partnership. Relationships are reported to have

improved and there is increased evidence of ‘joined up’ working. Children are seen

individually and their voices are heard and recorded. Practitioners reported that it is good to

be challenged, it is welcomed and that we are working in an environment where we need to

keep the children at the forefront.

The GSCB will receive the systems learning points, recommendations and challenge issues

set out in the SILP report and the additional section in order to produce a robust Response

Plan which will be monitored until completion of all agreed actions.

Janice Waters

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References

Department for Education. 2013. Working together to safeguard children [Online]. Available at: http://www.education.gov.uk/aboutdfe/statutory/g00213160/working-together-to-safeguard-children [Accessed: 12.07.2014].

Melia, P. et al. 1999. Triumvirate nursing for personality disordered patients: crossing the boundaries safely. Journal of psychiatric and mental health nursing 6, pp. 15-20.

Reason, J. 2000. Human error: models and management. Bmj 320(7237), pp. 768-770.

Reder P et al. 1993. In: Routledge ed. Beyong blame: Child abuse tragedies revisited. pp. 106-107.

Taylor-Adams, S. et al. 2004. Systems analysis of clinical incidents: the London protocol. Clinical Risk 10(6), pp. 211-220.

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Appendix 1

Interaction matrix to reveal where contributory factors impacted on the case

Child or family factors

Task Factors Frontline professional factors

Organisational factors

National factors

Judge’s sentencing comments

Peaks and Troughs Not a case of deliberate behaviour Physical disabilities

Psychotherapist’s feedback

Powerful personality disorder

Professional Splitting Systemic paralysis

Systemic Paralysis

Housing feedback Failure to access the home

Lack of record keeping Failure to access the home

Lack of record keeping

Practitioner Learning Event

Lack of healthy challenge Fear of family disengagement Parents difficult to work with Rights of the parents over the children

Lack of response by CSC

Lack of information sharing Agency drop off

Lack of robust plans